Mortality and RDI
7.0
< 59 yr
> 59 yr
6.0
Log Odds
5.0
4.0
3.0
2.0
1.0
0.0
-1.0
0-10
11.-20
20-40
RDI
>40
Long-term Cardiovascular Outcomes in Men
with OSAS
Controls n = 264
Snorers n = 377
Mild OSAH n = 403
Severe OSAH n = 235
OSAH with CPAP n = 372
JM Marin et al. Lancet 2005; 365:1046-1053
SLEEP DISORDERED BREATHING AND MORTALITY:
EIGHTEEN-YEAR FOLLOW-UP OF THE WISCONSIN SLEEP
COHORT
YOUNG ET AL. SLEEP, VOL. 31, NO. 8, 2008
Mean age 48 yrs
Marshall – Sleep 2008;
31: 1079-1085
Cardiovascular disease and mortality in OSAS patients
at baseline and after 10-yr follow-up
Doherty et al. Chest 2005; 127: 2076-2084
*
LOW COMPLIANCE TO TREATMENT
DECREASES SURVIVAL.
Campos-Rodriguez et al. Chest 2005; 128: 624-633
CAMBIAMENTI DI PERSONALITÀ E DISTURBI
DELL’UMORE
Depressione, irascibilità o aggressività
Alterazione delle funzioni psichiche superiori
• D E F I C IT D E L L ’ ATT E N Z IO N E E D E L L A M E M O R I A
•
D I F F I C OLTÀ D I C O N C ENTRA ZIO NE
• R ID OTTA A B ILITÀ M A N UALE PRO PO R ZIONALE A L N U M ERO D I
APNEE NEL SONNO
• S C A R S E P E R FO R M A N C E L AVO R AT IV E O D I ST U D IO P E R P RO B L E M I
V I S I VI E P S I C O MOTORI ; Q U E STE A LT ERA ZI ONI S O N O D OV UTE A L L A
FR A M MENTAZION E D EL S O N N O E A LLA C O N S EGUENTE IPO S SIA
CEREBRALE.
Table 3 – CBA 2.0 Schedule 4: answers’ frequency distributions
Inquiry Area
Answer
n (%)
Relationship with parents
Good
Poor
86 (67.7%)
41 (25.3%)
Couple relationship
Good
Poor
84 (72.4%)
32 (27.6%)
Sexual activity
Regular/satisfactory
Not regular/unsatisfactory
60 (43.5%)
78 (56.5%)
Sexual disturbances
No
Yes
94 (50.4%)
63 (49.6%)
Financial situation
Good
Poor
91 (53.2%)
66 (46.8%)
Smoking
No
Yes
98 (59.0%)
59 (41.0%)
Psychopharmacological treatment
No
Yes
144 (90.4%)
13 (9.6%)
Suicidal thoughts
Yes
No
12 (9.1%)
145 (90.9%)
Pierobon Sleep Medicine 2008
WHY WE NEED TO TREAT OSA?
OSA: high prevalence of erectile dysfunction
in man due to neuropathy development.
Strong correlation between the severity of
nerve damage and severity of nocturnal
hypoxia.
Fanfulla et al Sleep 2000
Riflesso bulbocavernoso in OSAS
normale
alterato
Eccessiva sonnolenza diurna
Sensazione soggettiva di un imperioso bisogno di
sonno in una condizione non usuale (tempo e luogo) o
episodio di addormentamento non intenzionale o in
una condizione non usuale (tempo e luogo).
American Sleep Disorders Association, ICSD.
DRIVING, SLEEP AND
ACCIDENTS
Effect of time of day (p<0.001)
Sleep-related accidents
Traffic density
Traffic Density
160
8
140
7
120
6
100
5
80
4
60
3
40
2
20
1
0
0
0
2
4
6
8
10
12
14
Time of the day
16
18
20
22
proporzionality ratio
n. of sleep related
accidents
Relative hourly probability risk
N of Sleep-Related
Accidents
Relative Risk of
Sleep-Related
Accidents
“ un guidatore viene definito come
sonnolento alla guida se diventa così
sonnolento mentre guida da aver paura di
addormentarsi e se tale severa sonnolenza
durante la guida compaia almeno una
volta su tre quando impegnato in un lungo
tragitto autostradale”.
RISK OF SLEEP APNEA IN SLEEPY
DRIVERS
60
5.7 (1.3-24)
52
50
6.0 (1.1-32)10.0 (1.5-66)
42
SWD
40
40
No SWD
% 30
20
17
13
9
10
0
>10
>15
>20
AHI
Confounding variables: hypertension, body mass index, gender, age and snoring
Masa AJRCCM 2000
Accidents risk in sleepy drivers with/without
sleep apnea
% of drivers with
accidents
60
50
6.6 (1.1-44)
8.5 (1.2-59)
8.9 (1.3-62)
47
43
50
Sleep apnea
No Sleep apnea
40
30
20
10
13
12
12
10
0
>10-<10
>15-<15
>20-<20
Drivers
Control
AHI
Confounding variables: hypertension, drugs causing sleepiness, body mass index, gender, age,
alcohol consumed, insomnia, hours slept per night, work and sleep schedule, professional drivers,
hours driven per month and years of driving.
SLEEP, DRIVING AND SLEEP APNEA
If we turn to medical matters, a recent meta-analysis points to Obstructive
Sleep Apnea as the disease resulting in the highest risks of being involved in
an accident with injuries
Low Risk Impairment
Vision, arthritis/locomotor,
Hearing, Cardiovascular
Relative risk < 1.25
Medium risk impairment Diabetes Mellitus
Relative risk 1.56
High Risk Impairment
Alcoholism, Neurological,
Mental, Drugs/Medicines
Relative Risk 1.58 –
2.0
Very High Risk
Sleep Apnea/Narcolepsy*
Relative Risk 3.71
(only one study on Narcolepsy)
Truls Vaa Impairments, Diseases, age and their relative risks of accidents involvement. Institute for
Transport Economics, Oslo, Norway, 2003
A 60 Km/h in 6 secondi si percorrono 100 metri
DRIVING ABILITY IN SLEEP APNOEA PATIENTS
BEFORE AND AFTER CPAP TREATMENT Mazza
ERJ 2006
Determinants Affecting Health-Care Utilization in
Obstructive Sleep Apnea Syndrome Patients
OSAS patients are heavy users of health-care
resources. Age >65 years and female gender were the
leading elements predicting the most costly OSAS
patients, and not necessarily patients with a high BMI
and classic OSAS severity indexes.
This was due to higher comorbidity, ie, 10 to 30%
more hypertension, ischemic heart disease, diabetes
mellitus, and pulmonary disease.
Ariel Tarasiuk, et al CHEST 2005; 128:1310–1314)
Low Socioeconomic Status Is a Risk Factor for
Cardiovascular Disease Among Adult OSAS Patients
Requiring Treatment
In addition to the already known
traditional risk factors, low SES was
found to be a novel independent risk
factor for CVD among adult OSAS
patients requiring treatment.
Ariel Tarasiuk, et al CHEST 2006; 130:766–773)
FUTURO
Identificare (HTA) nuovi modelli gestionali:
 Rete (modello HUB – Spoke – rete
assistenziale territoriale)
 Sistema piramidale (ambulatorio – DH –
Degenza)
 Reti ospedaliere
 Modelli integrati
FUTURO
Cosa si chiede alla politica sanitaria:
1. Riconoscimento della specificità della
medicina del sonno, compresa quella
respiratoria (ICD – Nomenclatore)
2. Il riconoscimento dell’OSAS come
malattia sociale
3. Escludere la CPAP dalla disciplina
protesica
CONCLUSIONI
Fare in modo che il futuro da “minaccia”
diventi promessa (o opportunità).